Box 14
Always Required?: No. Visits such as annual exams and physicals will not require an illness, injury or pregnancy date.
How to Complete: Enter the date of the first onset of the illness or injury that corresponds to the diagnosis listed for the patient. In the event of pregnancy, enter the date of the last menstrual period. Date format can either be 6 digit (MM DD YY) or 8 digit (MM DD CCYY).
Information Comes From: Patient Examination and/or Patient Information/History Form
Special Consideration: It is a good idea to check this date against the date that the insurance policy took effect. If you report an injury or illness or pregnancy prior to the effective date of an insurance policy, a “pre-existing condition”
will come into play.
Example:
Box 15
Always Required?: No, only if applicable.
How to Complete: Enter the date of the first onset of the similar illness or injury that corresponds to the diagnosis listed for the patient. Date format can either be 6 digit (MM DD YY) or 8 digit (MM DD CCYY).
Information Comes From: Patient Examination and/or Patient Information/History Form
Special Consideration: It is a good idea to check this date against the date that the insurance policy took effect. If you report an injury or illness or pregnancy prior to the effective date of an insurance policy, a “pre-existing condition” will come into play.
Box 16
Always Required?: No, only if applicable.
How to Complete: If the patient is employed and it unable to work due to the illness or injury reported, complete this area either with the 6 or 8 digit date format.
Information Comes From: Patient Examination and/or Patient Information/History Form
Special Consideration: It is a good idea to check these date against the date that the insurance policy took effect. If you report an injury or illness or pregnancy prior to the effective date of an insurance policy, a “pre-existing condition” will come into play.
Box 17
Always Required?: No, only if applicable.
How to Complete: If the patient was referred by another provider, enter then first name, middle initial, last name and credentials of the provider. Do not use commas.
Information Comes From: Patient Examination and/or Patient
Boxes 17a and 17b
Always Required?: No. Complete these boxes only if the patient was referred by another provider.
How to Complete: First box of 17a: Enter the alphanumeric qualifier. Second box of 17a: Enter the non-NPI ID (assigned to the provider by certain insurance carriers/payers) of the referring or ordering provider.
Box 17b: Enter the 10 digit NPI for the referring/ordering provider.
Special Consideration: For reporting to Medicare you will need to use the physician’s UPIN Number. UPIN stands for “Unique Provider Identification Number.”
Information Comes From: Patient Examination and/or Patient Information/History Form
Example: Thomas Davis was not referred by another provider. No example given.
Box 18
Always Required?: No, only if applicable.
How to Complete: If the procedures being reported for the patient are related to an inpatient hospitalization, enter the 6 digit or 8 digit “FROM” and “TO” dates.
If the patient has not been released from the hospital, leave the “TO” date blank.
Information Comes From: Physician’s Notes Example: No example.
Always Required?: No. In most instances, this is usually left blank.
How to Complete: Sometimes an insurance payer will require certain identifying information to be placed in this box. You will need to refer to the claim
guidelines from the payer to determine what, if anything, needs to be included in this box.
Information Comes From: Insurance Carrier/Payer
Box 20
Always Required?: No, only if applicable.
How to Complete: Are there any laboratory procedures listed on the claim form that were performed at an outside lab and not within the physician’s office? If so, place an X in the box next to “YES.” If not, place an X in the box next to “NO.” If “YES” is indicated, you will need to calculate the total charges for outside lab procedures and enter them into the $ charge section of this box.
Special Consideration: If “YES” is selected in Box 20, the name and address of the outside lab will need to be included in Box 32 of the CMS 1500 Form.
Box 21
Always Required?: Yes
How to Complete: Always using the highest level of specificity, list the ICD (International Classification of Disease) diagnosis codes relating to the
condition(s) that the patient is receiving services for.
This section represents WHY the patient is being treated. Only digits are
reported here. The written narrative/description of the diagnosis should not
List up to 4 diagnosis codes and always start with the most prevalent diagnosis first.
For Instance: A diagnosis which reflects “pain” isn’t always the most prevalent diagnosis. A diagnosis which provides the reason why the patient is experiencing the pain should always be listed before the diagnosis reflecting the pain caused by the condition, if and when possible.
Special Consideration 1: Careful consideration needs to be paid to the contents of this box. The insurance payer will carefully review this section in their
determination of “medical necessity.” Oftentimes an insurance payer will auto-assign an amount of procedures to fall within “medical necessity” based upon the diagnosis reported.
For Instance: Let’s say that a patient goes to see his physician because he is experiencing pain in his left elbow. The doctor/provider of services doesn’t know why the patient is experiencing pain in his left elbow, so the provider runs a series of tests to determine why the patient is experiencing pain. The first claim
submitted for the patient includes a diagnosis for “elbow pain” and reports all the tests run on the patient to discover why the patient is experiencing pain. The elbow pain diagnosis substantiates the tests run on the patient. But, the insurance payer will assign a reasonable amount of services to be performed for the elbow pain diagnosis. If the provider is sloppy about the contents of this box and does not continue to update the diagnosis to reflect the actual
condition/source of pain, and only continues to report just the elbow pain diagnosis, without reporting the condition found as the cause of the pain, eventually subsequent claims will be “kicked-out” for manual review for medical necessity.
Special Consideration 2: The ICD-9-CM code represents the diagnosis of the patient as connected to the procedures (CPT) that you will be listing in Box 24D. As the medical biller it is not your responsibility to identify an ICD-9-CM code. This needs to be coded and provided to you either by the physician or a physician’s coder!
Information Comes From: Superbill, Daysheet, Information from Provider Example:
Box 22
Always Required?: No, only if applicable
How to Complete: Complete this box if you are resubmitting a Medicaid claim.
You will need to refer to the requirements set-forth by the Medicaid intermediary (payer) in order to determine the proper completion of this box.
Information Comes From: Previous Medicaid Claim Submission and Medicaid Guidelines
Box 23
Always Required?: No, only if applicable
How to Complete: An insurance payer may require a prior authorization for certain procedures performed on a patient. Prior Authorization simply means that the insurance payer has been contacted and notified that a certain procedure needs to be performed. If the insurance payer approves the procedure which requires prior authorization, a prior authorization number will be provided by the insurance payer. This number is entered into Box 23.
Information Comes From: Insurance Payer Guidelines/Insurance Payer Box 24
This entire section of the CMS 1500 Form represents the WHEN, WHERE, WHAT, EXTENUATING CIRCUMSTANCES, AND $ HOW MUCH relating to the
procedures/services rendered to the patient.
Only 6 procedures can be listed in this section. If more services were provided, they must be reported on additional CMS 1500 claim forms.
Item Number 24A
Always Required?: Yes
How to Complete: Enter the “From” and
“To” dates that the procedure being reported was rendered.
Information Comes From: Superbill or Daysheet
Example:
Box 24B
Always Required?: Yes
How to Complete: Enter the 2 digit POS (Place of Service) code to signify where the services were rendered.
Place of Service Codes are two-digit codes placed on health care professional claims to indicate the setting in which a service was provided. The Centers for Medicare & Medicaid Services (CMS) maintain POS codes used throughout the health care industry.
Information Comes From: This really depends on the type of provider. If this is the type of provider who always performs the services in his office, then you will always report the 2 digit code for office (11).
Example:
Box 24C
Always Required?: No
EMG means “emergency indicator.” This box used to be used to report the TOS (Type of Service). TOS is no longer used.
How to Complete: Place a “Y” in the box if the procedure performed is related to an emergency situation. Leave the box blank if it is not.
Information Comes From: Patient Information Form, Patient Examination.
Special Consideration: The definition of an “emergency” may need to be verified by federal or state regulations or insurance payer guidelines.
Box 24D
Always Required?: Yes
How to Complete: Enter the 5 digit CPT (Current Procedural Terminology) or HCPCS (Healthcare Common Procedure Coding System) code under the CPT/HCPCS column.
Enter any 2 digit (up to 4) modifiers for each CPT or HCPCS code reported, if applicable.
The CPT or HCPCS codes reports “what service was done” and the Modifier provides additional, extenuating circumstances about the procedure reported.
At this point you may be feeling a little overwhelmed. I want to remind you that the purpose of this chapter is to familiarize you with the CMS 1500 Form. Don’t worry about codes and modifiers right now as this will fall into place for you in the next chapter.
Furthermore, you will be utilizing Practice Management Software that should definitely simplify the process of completing a CMS 1500 Form. Later in the course you will be entering your data into practice management software and you will witness just how easy the process can be.
Possessing a good understanding of the process is important and will allow you to appreciate the tools you will be utilizing to “get the job done.”
Information Comes From: Superbill or Daysheet
Special Consideration: Certain procedures, especially reported to Medicare, will require a modifier. Refer to the Medicare guidelines in your state.
Example:
In this example, three procedures are reported:
99201: Evaluation & Management Code 98940: (CMT Code) Spinal Manipulation 72070: X-Ray
The modifier -25 explains that the 99201 code is
“separate and significantly identifiable” and should be paid in addition to the 98940 code, which also includes a level of “evaluation and management.”
In some cases, if you did not modify the 99201 code with a -25, it would be denied due to being a “duplicate service.”
Box 24E
Always Required?: Yes
How to Complete: Enter the number of the diagnosis listed in Box 21 that the procedure on this line is related to.
You will notice that Thomas Davis only has one diagnosis. The procedures performed on Thomas are all related to that one diagnosis which is located in Box 21, number 1.
Information Comes From: Superbill/Daysheet Example:
Let’s say that Box 21 (Diagnosis or Nature of Illness or Injury) contains more than one diagnosis (let’s add two more) and that all the procedures listed in Box 24A relate to all the diagnosis listed in Box 21.
This is what Box 24E would then look like:
Box 24F
Always Required?: Yes
How to Complete: Enter the charge amount for the procedure.
Remember: Your software program will retain this
information and will automatically fill in this area for you. The software program will know the charge for each procedure because the procedures and their charges will have been entered into the system.
Information Comes From: Pre-loaded into the software system.
Example:
Box 24G
Always Required?: Yes
How to Complete: Enter the number of days or units. This field is most commonly used for multiple visits, units of supplies, anesthesia units or minutes, or oxygen volume. If only one service is performed, the numeral 1 must be entered.
Information Comes From: Superbill/Daysheet Example:
Box 24H
Always Required?: No
EPSDT = Early & Periodic Screening, Diagnosis, and Treatment How to Complete: Some state health plans (i.e. Medicaid) covers EPSDT and will require you to complete this box if the procedure is related to EPSDT.
Place a “Y” in the box to indicate “YES.” Place an “N” in the box to indicate “No.” If EPSDT isn’t applicable, leave this box blank.
Information Comes From: Type of Insurance
Box 24I
Always Required?: No
How to Complete: Enter the alpha numeric qualifier for the non NPI provider identifier number that is listed in the next box, Box 24J.
Since we are filing a claim to Blue Cross Blue Shield, we will be using the Qualifier 1B. Blue Cross Blue Shield requires the Blue Cross Blue Shield Provider Number for the rendering physician to be included in Box 24J.
There are also additional insurance payers who will require for you to identify the rendering provider with the number they have assigned to that particular provider in Box 24J of the CMS 1500 Form.
Remember: Your software program will know how to populate this box based upon the “type of insurance” that you select when you enter the insurance plan information for a patient.
Information Comes From: Insurance Information for the Patient Special Consideration: The Rendering Provider is the person or company (laboratory or other facility) who rendered or supervised the care. In the case where a substitute provider (locum tenens) was used, enter that provider’s information here.
Report the Identification Number in Boxes 24I and 24J only when different from data recorded in boxes 33a and 33b.
Example: Because we are filing Thomas Davis’ claim with Blue Cross Blue Shield of Indiana, we will be using the qualifier 1B.
Study Guide Reference your Study Guide for a list of Qualifiers.
Box 24J
Always Required?: No
How to Complete: Enter the Rendering Provider ID Number, if applicable, that has been assigned to the provider by the insurance carrier.
Since we are filing a claim to Blue Cross Blue Shield, we will be using the Blue Cross Blue Shield Provider Number for the physician, Marcus Welby.
There are certain insurance payers who will require for you to identify the rendering provider with the number they have assigned to that particular provider in this box.
Remember: Your software program will know how to populate this box based upon the “type of insurance” that you select when you enter the insurance plan information for a patient and the information you have entered for the provider.
Information Comes From: Provider Information
Special Consideration: The Rendering Provider is the person or company (laboratory or other facility) who rendered or supervised the care. In the case where a substitute provider (locum tenens) was used, enter that provider’s information here.
Report the Identification Number in boxes 24I and 24J only when different from data recorded in boxes 33a and 33b.
Example: Because we are filing Thomas Davis’ claim with Blue Cross Blue Shield of Indiana, we will be using the Blue Cross Blue Shield Provider Number for the provider, Marcus Welby.
Box 25
Always Required?: Yes
How to Complete: How does this particular provider/practice report their income to the IRS? If he/she reports as a group using an EIN (Employer ID Number), enter this number into Box 25. If the income is reported using an individual SSN (Social Security Number), enter this number into Box 25.
Place an “X” in the appropriate box for either SSN or EIN.
Information Comes From: Provider Information
Example: Our provider reports as a “group practice” using his EIN
Box 26
Always Required?: No
How to Complete: Enter the patient’s account number. This number can either be assigned by the provider’s office or it can be automatically assigned/generated through the software system.
Do not use hyphens or commas. Enter just the number or alpha numeric account identifier.
Remember: Your software will automatically populate this box.
Information Comes From: Patient Encounter Document/Patient Information Form
Example:
Box 27
Always Required?: No
How to Complete: Enter an “X” in the appropriate box to indicate whether or not the provider accepts assignment under Medicare or under any other
government plan being billed.
Contrary to what many others believe, this is not a duplication of Box 13! Selecting
“YES” in this box means that the provider has negotiated a participating provider contract and has agreed to accept the carrier-determined allowed fee for all services performed. Check “NO” if the provider has not signed a participating provider contract with the insurance carrier.
Some software programs will default to “YES” on all claims submitted based on the information that has been provided in the software.
Information Comes From: Provider Insurance Plan Agreement
Box 28
Always Required?: Yes
How to Complete: Enter the total of all charges listed in Box 24F.
Your software program will automatically calculate this for you.
Information Comes From: Adding the charges listed in Box 24F of the CMS 1500 Form
Example:
Box 29
Always Required?: No
How to Complete: Enter any amount paid by the patient or by another insurance carrier.
Information Comes From: Superbill/Daysheet, EOB (Explanation of Benefits)
I personally prefer to leave this box blank even if the patient or another payer has paid towards the claim. The reason being is because on more than one occasion, I have included an amount paid in this box, which will deduct the amount from Box 30 (Balance Due) only to have the insurance payer pay their portion on just the amount in Box 30. This then leaves a balance on the patient’s account that should have been paid by the insurance.
In the event that I would be billing a secondary insurance after the primary insurance has made their payment on a claim, I would attach the primary EOB (Explanation of Benefits) to the CMS 1500 claim form so that the secondary payer could see what was paid, but I would leave Box 29 blank.
For Instance: The patient has an insurance that pays 80%. The copay amount is 20%. The total charge = $100.00. The patient pays $20.00. You report the
$20.00 payment in Box 29 which gave a Balance Due (Box 30) of $80. The insurance payer looked at the $80 and paid 80% of the $80.00 Balance Due
($64.00) when they should have actually paid 80% of the $100 charge. This would then leave a balance on the claim of $16.00. It happens.
Box 30
Always Required?: Yes
How to Complete: Enter the Balance Due amount.
Information Comes From: Adding the charges on the CMS 1500 Form.
Example:
Box 31
Always Required?: Yes
How to Complete: Enter the name and the credentials of the billing provider and the date the claim form was generated.
Information Comes From: Pre-loaded into the software program Example:
Box 32, 32a and 32b
Always Required?: No, only if applicable
How to Complete: If the procedures listed were rendered at a location other than the provider’s office or patient’s home, enter the name and address of the facility here. If you have selected “YES” in Box 20 of the CMS 1500 Form, you will need to
How to Complete: If the procedures listed were rendered at a location other than the provider’s office or patient’s home, enter the name and address of the facility here. If you have selected “YES” in Box 20 of the CMS 1500 Form, you will need to